The process of diagnostic reasoning starts with the medical history. The validity of the history is highly dependent on the mastery of the relevant content, more so than a general diagnostic strategy. Expert clinicians focus more on relevant information, and are highly selective in their use of the retrieved data. The medical history is complemented by the physical examination. See also the article on diagnosis.
Goals of History Taking
One view of goal of medical history taking is to obtain information that will help to provide effective treatment, i.e. treatment that will produce a better outcome than can be expected from the natural history. This view, which can be reformulated as a diagnosis having only "positive therapeutic utility" is clearly an incomplete view. Many conditions don't need treatment, and a diagnosis alone is all that is sufficient, i.e. there is simply a "diagnostic utility". For example precordial catch syndrome, non-painful slipping ribs, or non-painful clicking joints. Furthermore many conditions don't have a treatment, and a diagnosis is all that can be provided, and it may stop further unnecessary treatment. This can be reframed as "negative therapeutic utility."
The history is also used to alert the doctor to the possibility of red flag conditions, i.e. clinical features known to be correlated with serious pathology.
Other than the utility in the process of diagnostic reasoning, the history is used to elicit patient ideas (how they perceive their situation), concerns (what they are worried about), and expectations (what they hope to get out of the consultation). It also lays the foundation for the clinician-patient relationship and builds rapport.
Furthermore, in vulnerable populations it is used to elicit certain social needs that may be able to be actioned upon. For example an elderly person who is struggling at home with activities of daily living.
Traditional vs Chief Complaint Driven Medical History
The traditional method of obtaining a medical history follows a sequential series of 'siloed' categories of information. It starts with the presenting complaint, moves on to the history of presenting complaint (e.g. SOCRATES mnemonic for pain), past medical history, family history, social history, and review of systems. Once all the data is gathered only then is everything integrated.
Expert clinicians tend to rather follow a chief complaint driven history taking. The chief or presenting complaint immediately generates a list of diagnostic possibilities; in fact the most important determinant of whether the correct diagnosis was reached is if that diagnosis was on the initial list of possible diagnoses. The clinician then constantly reformulates and tests hypotheses and in doing so is simultaneously problem solving as they elicit the history. The clinician selects a small number of elements from areas of the history as needed to either support or refute different hypotheses, forming the pertinent positives and negatives. In this manner, each question is a test. The selected elements are often dichotomous and exist within the context of the diagnostic schemas and illness scripts in the mind of the clinician.
The key differentiating factor between novices and experts is knowledge. Clinical reasoning is not simply a general process of problem solving, but is dependent on knowledge in that specific domain, requires specific cognitive processes for specific tasks, and is also experience specific. Strategy is less important than mastery of the content.
An example of how the traditional approach is not always used by expert clinicians is acute knee pain. A key question here in the diagnostic schema is going to be a history of trauma. In the setting of trauma other key questions may include the mechanism and a history of swelling. A skiing injury is going to put the possibility of internal knee derangement high on the list of possibilities and subsequent questions may be directed at that. With a lack of trauma, some key questions may include a history swelling and fever, and a past medical history of osteoarthritis and gout. Contextual factors are also important. If a Pacific Islander presents with an obviously hot and swollen knee, the first question is probably going to be whether there is a past history of gout.
The traditional vs chief-complaint driven approaches are likely not a dichotomy but rather exist on a spectrum. Looking at it from a dual process theory perspective, chief-complaint driven processes are problem more useful for simple problems, while the traditional approach may be more useful for complex problems.
Traditional Comprehensive Medical History
Some advocate that history taking should be systematic and thorough so that important issues are not overlooked. However, as discussed above, this type of systematic approach has been shown to not be diagnostically useful to expert clinicians. The data do not support that a comprehensive history leads to better diagnostic accuracy.
However, one important aspect in history taking is for the doctor to be cognizant of "red flag" clinical features that raise concern for serious pathology such as infection or neoplasia. It seems reasonable to assume that for identifying rare conditions such as red flag conditions the traditional approach may be superior, as it is generally thought that being systematic with red flags is important. Using a red flag checklist may aid in this endeavour in alerting the clinician to potential serious causes. Red flags should be assessed at the initial encounter and at every subsequent encounter.
The doctor should initially ask a very broad open question related to the reason for their presentation, and not interrupt their initial answer. Often patients will talk for a couple minutes and give many helpful clues. Also many patients will from the outset relay their ideas, concerns, and expectations.
There are nine domains in the comprehensive medical history:
- presenting symptom(s)
- history of the index condition (history of presenting or chief complaint)
- intercurrent conditions
- intercurrent medical treatment
- general medical history
- systems review
- psychological history
- social history
Identification: patient's name, age, ethnicity and demographic, lateral dominance, and occupation.
Presenting Symptoms: All symptoms are listed and ranked according to their significance to the patient. The main symptom is termed the index condition.
History of the Index Condition:
This is explored systematically in the traditional approach to medical history taking. There are fourteen specific aspects:
- site: The topographical region, noting differences in taxonomy between the doctor and patient. For example some patients may call pain in their iliac crest region "hip pain". Also keen in mind the possibility of referred pain, and so ask where their "main" pain is, where it is felt the worst, or where it is felt most often or most consistently. Also reciprocally ask where they feel the pain only sometimes.
- distribution: The pain distribution is diagnostically useful in certain conditions such as cervical pain and sacroiliac joint pain. Pain maps for other areas have also been developed, with less diagnostic validity. The possibility of visceral pain should be considered.
- quality: Somatic pain is typically a dull, aching pain. This character of pain radiating from the spine to a limb suggests somatic referred pain. Radicular pain is typically sharp and shooting that extends in a thin band from the spine to the limb. Neuropathic pain is often described as burning in quality.
- duration: In order to classify the pain as acute, subacute, or chronic. This has implications on prognosis and treatment strategies
- periodicity: This refers to the amount of time a pain is present, e.g. constant or intermittent. Neurogenic pain is classically periodic. Periodic pain may also suggest certain structures that are painful under the time of or following load.
- intensity: The numerical rating scale and visual analogue scales are the most commonly used here.
- aggravating factors: This can potentially be useful diagnostically, for example pain with lying on the lateral hip in gluteal tendinopathy. If the pain isn't aggravated by biomechanical loading then this could raise the possibility of referred pain. It can also help guide treatment recommendations for how to avoid the pain, e.g. identifying that many of the aggravating factors are certain compressive postures in gluteal tendinopathy.
- relieving factors: The pain experienced in serious conditions may not be relieved by rest.
- effects on activities of daily living: This information provides an estimation of their level of disability or function. It can also be used as a metric for monitoring progress along with pain intensity.
- associated symptoms: This mainly has to do with identifying serious causes. Associated symptoms include fever, malaise, weight loss, night sweats, neurological symptoms, and transient ischaemic attacks.
- onset: The first appearance of the pain. In particular whether it came about following trauma (direct blow, indirect blow, skin penetration etc), and a detailed mechanical nature of the trauma.
- previous similar symptoms: suggesting a chronic or recurrent conditions.
- previous treatment: what exactly they have had and the outcomes. For example, a patient may have had a corticosteroid injection in a facet joint. They may say it didn't work, but this only refers to the therapeutic aspect. The diagnostic aspect should also be explored, i.e. see if the response to the local anaesthetic was recorded.
- current treatment: This includes treatment from other people (who may or may not be healthcare professionals) and self-applied treatment.
- intercurrent conditions: Other problems occurring with the index condition, with attention paid to possible red flags.
Other Current Medical Treatments: All forms of treatment for other conditions. For example if a patient is on a thiazide and ACE inhibitor for their hypertension, you won't prescribe an NSAID.
Past Medical History: Certain conditions in the past history may be relevant. They are too numerous to list but some examples are psoriasis (spondyloarthropathy), past history of cancer (recurrence or metastases), coronary artery disease (vascular as opposed to neurogenic claudication), and prolonged use of glucocorticoids (stress fracture).
Systems Review: Past or present symptoms from each bodily system.
Psychological History: Note any psychological distress as a consequence of the index condition, or whether there was any pre-existing psychological conditions. Psychological risk factors are associated with the level of disability with chronic pain. The assessment should include determining their affect, cognitions and beliefs, and coping strategies. Adverse childhood experiences may be relevant, in particular to the patient's resilience. If significant concerns arise then psychological therapy should be offered if available in the area.
Social History: Family, close relationships, home, occupation, education, hobbies, smoking history, alcohol history, etc.
Patient-Centred Clinical Interviewing
Yet another model is the patient-centred clinical method which puts the biopsychosocial theory into practice. It views the traditional model as being overly biomedical and more suitable to acute presentations, which was more common when the model developed. In the current day, much of the interactions with patients are about managing chronic conditions.
This model views the doctor as eliciting two sets of content from the patient. Namely, the traditional biomedical history and the patient's illness experience. The patient-centred model therefore is based on the integration of the disease framework and the illness framework, where the doctor weaves between the two.
The illness framework is essentially the patient's perspective. It includes their ideas, concerns, expectations, thoughts and feelings, effects on life. The goal is understanding the patient's unique experience of illness. Contrast that to the goal of the disease framework which is generating a differential diagnosis.
Reliability and Validity
In the musculoskeletal setting, there is unfortunately little data on the reliability and validity of items in the traditional medical history.
Reliability: One study on patients with longstanding shoulder pain found that only 15/23 items on history had moderate interobserver reliability (kappa > 0.4), with 6/23 having good reliability (kappa >0.6).
Validity: A systematic review of hip osteoarthritis found that only medial thigh pain had validity but this was a rare symptom. On back pain, one study showed poor overall validity. Another found that the most useful features for predicting malignancy in back pain were past history of malignancy (LR+ 15.5), failure to improve with treatment (LR+ 3.1), and age over 50 (LR+ 2.7). On rotator cuff tears, many historical feature had poor validity.
- ↑ 1.0 1.1 1.2 Nierenberg R, 2020, 'Using the Chief Complaint Driven Medical History: Theoretical Background and Practical Steps for Student Clinicians ', MedEdPublish, 9, , 17, https://doi.org/10.15694/mep.2020.000017.1
- ↑ Mandin, H., Jones, A., Woloschuk, W. and Harasym, P. (1997) ‘Helping students learn to think like experts when solving clinical problems’, Academic Medicine, 72, pp. 173-179. https://doi.org/10.1097/00001888-199703000-00009
- ↑ 3.0 3.1 Wade King. Medical History. Encyclopedia of pain. 2013
- ↑ Ford, Sarah. “Patient‐centered Medicine, Transforming the Clinical Method (2nd edition).” Health Expectations : An International Journal of Public Participation in Health Care and Health Policy vol. 7,2 (2004): 181–182. doi:10.1111/j.1369-7625.2004.00270.x
- ↑ Nørregaard J, Krogsgaard MR, Lorenzen T, et al Diagnosing patients with longstanding shoulder joint pain Annals of the Rheumatic Diseases 2002;61:646-649.
- ↑ Metcalfe, David et al. “Does This Patient Have Hip Osteoarthritis?: The Rational Clinical Examination Systematic Review.” JAMA vol. 322,23 (2019): 2323-2333. doi:10.1001/jama.2019.19413
- ↑ Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992; 268: 760-765.
- ↑ Deyo RA, Diehl AK. Cancer as a cause of back pain: frequency, clinical presentation and diagnostic strategies. J Gen Int Med 1988; 3: 230-238.
- ↑ Litaker D, Pioro M, El Bilbeisi H, Brems J. Returning to the bedside: using the history and physical examination to identify rotator cuff tears. J Am Geriatr Soc 2000; 48:1633-1637.
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